Address
City State Zip
Phone Fax Country
Person
Treated with metoclopramide and/or propulsid
Name
Birthdate
Metoclopramide Treatment begun on date
(click
here for )
approx. weight when beginning prescription
Treatment discontinued date
Propulsid Treatment begun on date
(click here for )
approx. weight when beginning prescription
Treatment discontinued date
Below is a list of symptoms
reported as adverse reactions to these medications. You are not expected
to understand all these terms. If you do not understand a term, pass it, because we have
included many lay terms which may describe those medical conditions which you may not
understand. Simply fill in the dates of all the symptoms or conditions which you or your
loved one has experienced anytime after being treated with metoclopramide
or propulsid. If a condition was experienced prior to treatment with the medication(s)
and did not worsen the pre-existing condition, leave it blank . For new symptoms appearing after a medication was initiated give
the month and year (mm/yy) the symptom began and if it resolved, put the date it resolved.
If a symptom became obviously worse after beginning
medication, check the appropriate box(s) under the medication in which the symptom
worsened.
Date Began (or diagnosed)
Symptom
Worsened After
metoclopramide /
cisapride
insomnia
ADHD
"acting out"
mania
hyperactivity
anxiety/nervousness
autism
hallucinations
hypotonia
hypertonia
muscle cramps
muscle spasms
muscle weakness
muscle rigidity (stiffness)
chronic stiff neck
posturing
abnormal facial movements
abnormal tongue movements
torticollis
convulsions
abnormal (EEG) electoencephelogram
seizures
epilepsy
shivering
tremors
tics
Tourette Syndrome
Parkinson's
jerky movements
fevers of unknown (daily fevers) origin
high fever
brain atrophy
abnormal MRI
unknown neurological disorder
Neuroleptic Malignant Syndrome
Tardive Dyskinesia
extrapyramidal symptoms
Dystonic Reaction
Autoanomic nervous system imbalance
speech disorder
gait abnormal
movement disorder
palsy
paralysis
tinnitus
ringing in the ears
oculogyric crisus
eye rolling
abnormal eye movements
eyelid retraction or blinking
vision abnormal
transient blindness
aggression
irritability
depression
suicide attempt
anhedonia
amnesia
fatigue
lethargy
somnolonce
confusion
depressed level of consciousness
loss of consciousness
psychotic disorder
increased sweating
headache
migraine
dizziness / vertigo
salivary hypersecretion
choking
eating/feeding problem
apnea (including sleep apnea)
asthma
grunting
pulmonay distress
oxygen dependent
respiratory failure
respiratory rate increased
respiratory disorder
pulmonary congestion
pulmonary edema
pulmonary hypertention
pleural effusion
laryngitis
laryngeo spasm
bronchospasm
bronchitis
nasopharyngitis
croup
stridor
esophogeal spasm
cyanosis
flushing
hypoxia
obstructive airway
dyspnea
shortness of breath
ventricular hypertrophy
valvular heart disease
cardiomyopathy
cardiomegaly
bradycardia
tachycardia
increased heart rate
decreased heart rate
enlarged heart
heart failure
cardiac arrest
cardiac arrhythmias
Long QT Syndrome
myoglobinemia
myglobinuria
urine discoloration
urinary frequency
urinary tract infection
urinary incontinence
urinary retention
abnormal urinalysis
decreased urine output
blood in urine
blood urea increased
hydronephrosis
pyelonephritis
nephritis
nephrotic syndrome
blood creatinine increased
blood creatine phosphokinase increased
metoclopramide / propulsid
adrenal insufficiency
renal failure
renal impairment
renal tubular acidosis
renal disorder
hypokalemia
low blood potassium
elevated blood potassium
hypoglycemia
hyponatremia
low blood sodium
high blood sodium
gall bladder disorder
decreased resistance to infection
sepsis
blood infection
pancytopenia
haematoma
hypogammaglobulinemia
thrombocytosis
thromopenia
increased platlets
decreased platlets
increased white blood cells
decreased white blood
leukocytosis
leukopenia
enterocolitis
gastroenteritis
colitis
abdominal distention
constipation
ileus
chronic diarrhea
diarrhea
intestinal psuedo-obstruction
intestinal motility disorder
inflammatory bowel disease
gastro-intestinal ulcer
gastritis
malaena
intestinal bleeding
Steven Johnson Syndrome
oral/skin blisters
dermatitis
Epidermal Necrolysis
skin lesions (burnlike)
pregnancy loss
death
Additional
Comments/Symptoms
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